Cantwell warns RFK Jr. his agency's AI program is delaying, denying Medicare for seniors in Washington state

WASHINGTON - A federal pilot program that uses artificial intelligence to crack down on "wasteful" medical procedures is slowing and denying health care for senior citizens in Washington state who rely on Medicare, a Democratic senator told Health Secretary Robert F. Kennedy Jr. on Wednesday.

Since January, Washington has been one of six states chosen by the Department of Health and Human Services to test the new AI-assisted model, known as Wasteful and Inappropriate Service Reduction, or "WISeR." In a Senate Finance Committee hearing Wednesday, Sen. Maria Cantwell of Washington told Kennedy the program has resulted in Medicare coverage being delayed or denied for treatment seniors need.

"What's happening is AI is being used as a denial device for the CMS system," Cantwell said, referring to the federal agency that administers Medicare. "I have doctors calling me about this, I have patients calling me about this, so I would appreciate if you'd take a look at it."

After Cantwell cited reporting by the Seattle Times that highlighted an 83-year-old man who was denied Medicare coverage for a spinal procedure to treat debilitating nerve pain, Kennedy called that case "unacceptable" and pledged to work with Cantwell's office on it, but the health secretary defended the pilot program's goals.

"We found we were being ripped off by certain categories of procedures that are not good for the patient, and a lot of time they're unnecessary and they're very lucrative for the doctors," Kennedy said. "The AI targets those, and I don't know what happens then. But anyway, it shouldn't be delayed and we will try to work with you to fix it."

Since Congress created Medicare in 1965 to provide health care to Social Security recipients, the program has evolved to cover younger people with certain disabilities and to include a private-sector option known as Medicare Advantage. Medicare cost taxpayers $1.8 trillion in the fiscal year that ended in September, or nearly 18% of the federal budget, a number that has risen steadily as the U.S. population ages and the nation's health care system has grown increasingly costly.

Any serious attempt to reduce federal budget deficits and tackle the nation's $39 trillion debt would need to address growing Medicare costs, but executives who lead health care systems in Washington state say traditional Medicare is a relatively efficient and low-cost part of the system, while the WISeR program adds administrative costs and takes limited resources from providing health care. WISeR also relies on private companies that are paid based on how many claims they deny, creating an incentive to withhold care while redirecting taxpayer dollars from health care and toward those companies.

Andrew Jones, a medical doctor and CEO of Wenatchee-based Confluence Health, said WISeR fundamentally changes Medicare by requiring prior authorization before patients can be treated - a requirement that has previously defined private health insurance.

"One of the biggest advantages of traditional Medicare, as opposed to Medicare Advantage or any other insurance, is that it's really straightforward, transparent, relatively low overhead for everybody," Jones said. "It makes it easy to do business with Medicare, which makes up somewhat for the payment rates, which are a little below the market rate."

Confluence Health operates hospitals and clinics throughout central Washington, from Wenatchee to Oroville and Moses Lake. Jones said requiring prior authorization has forced Confluence to redesign its administrative processes, spending more time and money on processing claims, which can be especially challenging for largely rural health care systems like his.

"That's essentially pure waste," he said. "It's wasteful money we've had to spend and hassle for our providers. It takes funds away from patient care and other stuff we'd like to spend it on."

So far, the WISeR pilot program only applies to a small number of procedures, largely for spinal conditions. In Wednesday's hearing, Kennedy said the program also targets wasteful Medicare spending on skin substitutes - materials that are used to cover wounds while they heal - which he said increased from $250 million to $23 billion in three years.

"It's supposed to allow us to detect fraud early," Kennedy said to Cantwell. "There's probably kinks in the system. I will work with you to try to straighten that out. But as I said, we were being ripped off for $23 billion just for one category of procedure."

An analysis by the nonpartisan health care research organization KFF in February found that the services targeted by WISeR accounted for $12.3 billion in 2024, or 5.3% of spending in Medicare Part B, the part of traditional Medicare that covers doctor's visits and outpatient care. Those same services accounted for just $2.4 billion in 2019, or 1.1% of Medicare Part B spending.

The vast majority of that increase has been driven by rising prices for skin substitutes, according to KFF. The Centers for Medicare and Medicaid Services, which administers Medicare, enacted nationwide changes to its payment policy in January that the agency estimates will reduce Medicare spending on skin substitutes by 90%, which could reduce the purported benefits of WISeR.

Jones agreed that controlling health care costs is important, but he said the WISeR program has had the opposite effect.

"This doesn't help us do that," he said. "This actually increases the cost of care. It doesn't decrease the cost of care."

After proposing reforms in March to reduce overpayments to private companies through Medicare Advantage that are projected to cost taxpayers $1.3 trillion over the next decade, the Trump administration reversed course weeks later and proposed increasing spending on the program.

While the pilot program's scope is limited for now, Jones said it should be stopped before it expands and restricts a wider range of medical treatments. Most of the procedures affected by WISeR so far are spinal injections and other treatments for pain relief, he said.

"These are patients who are pretty miserable to begin with," Jones said. "You don't have someone stick a needle in your back because you feel good, so they're already suffering, and this just adds to their suffering by having to do the back-and-forth."

Cantwell's office published a report Wednesday that uses data from the Washington State Hospital Association to show that in 2024, more than 18,000 seniors in Washington used the services covered by WISeR with the help of Medicare. According to that data, urgent procedures that were previously approved in one day now take 15-20 days for approval as a result of WISeR, while those approved in weeks before the pilot program now take 4-8 weeks.

Susan Stacey, CEO of Providence Inland Northwest, said in a statement that physicians across the health care system she oversees - which includes Sacred Heart Medical Center and Holy Family Hospital in Spokane - "are concerned about the lack of clear information and predictability surrounding the WISeR program."

"Uncertainty about what services may be denied and how to navigate the review process is creating operational challenges and could place additional cost pressure on providers that are already struggling," Stacey said. "Our priority is ensuring patients can continue to receive timely, medically appropriate care while clinicians are able to spend their time focused on patients, not navigating complex administrative processes."

Washington Democrats have introduced legislation in the House and Senate to repeal the WISeR pilot program, but Republicans control both chambers and no GOP lawmaker has sponsored either bill. The House Appropriations Committee did approve an amendment to block funding for WISeR in September, showing some degree of bipartisan opposition to the program, but that provision was not included in the government funding package that became law in February.

In addition to Washington, the WISeR program is being piloted in Texas, Arizona, Oklahoma, Ohio and New Jersey. The test period is set to run through the end of 2031.

Orion Donovan Smith's work is funded in part by members of the Spokane community via the Community Journalism and Civic Engagement Fund. This story can be republished by other organizations for free under a Creative Commons license. For more information on this, please contact our newspaper's managing editor.

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